Presumptive malaria treatment of children with fever vs. Laboratory-confirmed diagnosis

The full article, published 9 January, 2009, can be found at PLoS Medicine

Paul Chinook at Tropika.net writes an editorial and summary of the PLoS article:

In African children, malaria has been both the commonest cause of fever and the commonest cause of death. Unsurprisingly, therefore many clinicians believe that the correct cause of action when seeing a child with fever is to presume that malaria is responsible and to treat accordingly. This is indeed what is recommended in the current WHO Guidelines for the Treatment of Malaria. However, in recent years the proportion of fevers due to malaria has become significantly lower, even in highly endemic areas. Rapid diagnostic tests (RDTs) for malaria are also now on the market. Is it therefore time for a policy change?

In the first part of a PLoS Medicine debate Genton et al. make the case for change, recommending that all febrile patients be diagnosed first, before providing treatment. They say that RDTs are reliable, easy-to-use and inexpensive, thus making such a new approach the safer option. They do, however, note that any such policy change would have to be carefully planned.

But would this be another case of "running before we can walk"? The opposing view, presented in the second half of the debate by English et al. is that health systems do not, at this stage, have the capability to implement such a change. They also question some of the evidence as to the reliability of RDTs.

As English et al. point out, Africa's weak health systems still have major problems in delivering treatment drugs to those who need them. They believe that delivering a new commodity (RDTs) - and providing the necessary staff training for their use - will be beyond the ability of many African health services. They also draw attention to an important behavioural issue; it is likely that if a child with a fever is not given malaria drugs at a health facility then the parents will respond by obtaining them from a retail outlet. This would create an extremely confusing situation.

In other words English et al say that we need more time before policy can be changed. Replying to this viewpoint Genton et al, say: "The time needed to achieve all conditions English et al. consider necessary to have a policy change will only lead to more deaths due to diseases other than malaria left untreated and to the emergence of parasite resistance consequent to irrational use of drugs."